Keep on singing when life’s a breech

This post was originally published in Birthspirit Midwifery Journal 2009; 1: 64-65. Updated.

KeepOnSingingWhenLifesABreechAs steeped in medically and midwifery managed birthing as this 60-plus year old breech story Randall (1949, pp. 81-84) is, it has (at least) three central themes – a woman who was confident about giving birth, an active (until the end), non-medicated labour, and a skilled, though medicalised, practitioner who supported vaginal breech birth.

These themes have undergone remarkable shifts in the last 15 years, and not only because the Term Breech Trial bedded down surgical birth for breech babies. Preceding that, the significant loss of breech skills by medical practitioners and midwives had begun and, as a result, an increasing loss of confidence to support women during labour and birth with their breech babies, was becoming evident.

Attempts are being made to address this loss of skills and build confidence. On an international level, the 2006 1st International Breech Birth Conference in Vancouver brought together many of us who are passionate about, and actively working towards, regaining and retaining these skills, and networking is ongoing. At the end of last year I presented at an education session for obstetric registrars in South Auckland on active breech birth and, while these obstetricians-in-training lamented their lack of experience with vaginal breech birth, there was a genuine desire from some of those present to acquire those skills. Facilitating breech birth is a component of ongoing education offered for registered midwives beyond the initial undergraduate education. Finally, there is good support amongst hundreds of midwives in New Zealand, both that I have spoken with, and where the issue is debated Health & Disability Commissioner (2006), to support women during physiological breech birth (at least) where they cannot get obstetric support.

While debate and ongoing knowledge development of active breech birth will be addressed in subsequent issues and in other fora, it is high time we start to consider some midwifery issues which run alongside skills development so midwives feel safe and supported to care for women during vaginal breech birth:

  • When it arises, what are we doing to address the giving, despite an evidence-informed guideline New Zealand Guidelines Group (2004), of inappropriate, scare-mongering information during obstetric consultation that gives rise to the commonly heard – “if a woman wants to give birth naturally before she sees the obstetrician, she certainly changes her mind after consultation with him”?
  • Where is the critique of commonly used midwifery texts, for example for example, for an example see Pairman et al (2010, p. 831) illustrating a passive, disembodied and bedbirthing woman and baby, with text giving de facto approval of routine, interventionist and unsafe strategies to ‘deliver’ breech babies when in a hospital environment?
  • Do we give voice to the role of a midwife as the primary birth attendant for women with breech babies?
  • How do we ensure midwives called upon to give ‘expert’ advice to investigatory bodies endorse midwifery, rather than obstetric, strategies for facilitating breech birth?
  • Is it ‘right’ to ‘lie low’ about breech birth in the hope that media attention will fade?

Pausing to reflect on these issues alone, and having robust and overt discussion within the profession, may offer Mrs F some hope of support for physiological breech birth should she labour today.

A toe in the water: exploring breech waterbirth

This post was originally published in Birthspirit Midwifery Journal 2009; 3: 15-19. Updated 2 February 2017

I am often asked during breech workshops that I run if leaving a woman in a birth pool to give birth to a surprise breech baby, undiagnosed until on the perineum, was ‘reasonable’ midwifery practice. The question is usually qualified by “if the breech baby had been known prior to labour, the birth would definitely not occur in water as it is contraindicated in all the waterbirth guidelines in New Zealand”. My initial reaction, though fleeting, was to shrink away and not own my own experiences, knowing that these would be viewed as ‘unreasonable’ given that guidelines were presented as a self-evident truth that could not be argued with, that is, a known breech baby would not be born in water.

The issue of breech presentation and waterbirth is one that I have repeatedly explored in the midwifery and obstetric literature over the years and have found little written on the subject. What is there usually cites the same source – Herman Ponette (undated1), the Belgium obstetrician in Ostend who actively promotes waterbirth with breech babies.There is minimal acknowledgement that it occurs in hospitals in the USA and the UK Harper (2000); Kitzinger (1991). Googling the term ‘breech waterbirth’ brings up an occasional consumer story (Katie, 2017) and the occasional midwifery website which discusses the issue. Increasingly, videos such as the one below are appearing on the web and numerous stories I receive from women and midwives about breech birth involve the use of water.

This article pieces together some knowledge gained from reading, discussions, several of my experiences of, and reflections on, the use of water immersion with breech babies.

Going with the flow

Initially I had been mindful of Michel Odent’s recommendation of not using deep warm water during breech labour as he warns that the soothing effect of water may mask an unduly painful labour, thereby preventing early detection of what may prove to be a problematic birth Odent (1984).

My own first experience of using water in a breech labour happened by accident in that the frank breech baby remained undiagnosed until on the perineum. The woman had used the pool unconventionally in labour – she chose to lounge in the pool between contractions and stood during them. Once the breech was diagnosed I asked her to leave the pool and she stood to give birth.

This made me re-look at Michel’s caution. My experience of waterbirth with cephalic presentation had shown me that water immersion only mellows out normal labour pain, not severe or pathological pain, which would indicate the bone-on-bone pain of true disproportion between pelvis and presenting part. I had to question why this should be any different for a breech presenting baby – and I could not find an answer.

With the same woman’s second frank breech baby, this time diagnosed in pregnancy, she again used the pool unconventionally to relax between her contractions, and she birthed standing on dry land. These two experiences marked a small shift in the use of water during my attendance at breech labour and birth in that water immersion remained available with a known breech. However, I continued to arrange with women that they would leave the pool for birthing.

This request changed following the birth of Heath, a firstborn presenting as a flexed legs breech. His mother had been deeply relaxed in the pool, assuming a wide open kneeling position leaning over the edge of the pool. When the baby was visible on the perineum, and the urge to push was overwhelming, I asked the woman to leave the pool as we had prearranged, which she did. Whereas she had been strong, independently held her own weight, and was powerful in her pushing, once out of the pool, she needed physical support to be in active birth positions and was unable to relax deeply between contractions as she had previously done in the pool. The baby was born within half an hour of pushing and all was well but it was clear to me that I had intervened in a physiological birth and this had altered the ease with which the woman gave birth.

This birth occurred some months after the 1st International Waterbirth Conference in 1995. Publication of Paul Johnson’s (1996) classic article on the mechanisms that prevent or, conversely, stimulate breathing in the unborn baby during waterbirth would occur the following year but, in concluding his conference write up, Johnson, a Consultant Clinical Physiologist in the O&G Department at the John Radcliffe Hospital in Oxford, wrote: “…if the onset of labour is spontaneous, and no drugs are administered, a fetus born with its cord intact, into warm, fresh water, not asphyxiated, is inhibited from breathing” Johnson, in Lawrence Beech (1996, pp. 31-33), a process not dependant on presentation. Initiation of breathing following waterbirth occurs once the baby surfaces and is exposed to cooler, dryer air and clamping the umbilical cord Johnson, in Lawrence Beech (1996), again, irrespective of presentation. Sheila Kitzinger would report his additional comment that “if water births are of psychological and physiological benefit, it is logical that this benefit should apply to high-risk women too” Kitzinger (1995).

I knew deep water immersion to be a very powerful modality for achieving a relaxed state for the woman, enhancing vasodilation and placental perfusion and, therefore, oxygenation, of the tissues and organs, including the placenta during the normally stressing (not distressing) time of labour. I had seen women become oblivious to everyone and everything as they sank into the pool. I had come to recognise the depth of sigh on entering the pool that signalled release of pain, fear, social etiquette and conversation – and these observations were irrespective of whether the baby was coming head or bottom first.

The buoyancy and warmth of water

Another dimension was added when I attended a woman with twins, the second baby being a breech presentation. The woman had grown her babies well and began labour spontaneously at 40 weeks. Due to the heaviness of her abdomen, she was drawn to labouring in water – her bath at home then, when labour was well established and she had travelled to her chosen birth place, the spa bath in the obstetric hospital. There was a point in her labour where she needed to be more upright than reclining in the spa bath allowed, so we set up my free standing birth pool for her. With the water up to the level of her breasts she became almost weightless in the pool, and was able to assume her intuitive positioning in a deep squat for the births of both her babies, the second of which had remained breech. The woman reflected how supportive the water had been and how the upright position engaged her strength and ability to birth well.

Controlling pelvic pressure

When vaginal breech birth was a common occurrence 15 or so years ago, epidural anaesthesia was commonly recommended to overcome a premature urge to push. However, discussion with midwifery colleagues indicates a premature urge to push with a term breech baby is rare in woman-controlled positioning.

One woman who did experience significant pelvic pressure from the onset of labour with spontaneous rupture of membranes while having her first baby – a frank breech presentation – provided a piece to the mosaic of the use of water. She controlled the urge to push by long and slow breathes during contractions and lying on her side on a floor mattress for most of her labour, rising only to crawl to the toilet on her hands and knees. After 12 hours of this, the pressure was overwhelming, even when lying. While her good progress was evident from the lengthening burgundy buttock crease and her birthing energy, it was not time to use that expulsive energy. A vaginal examination confirmed a thin rim of cervix remained. While a hands and knees position reduced the pressure, it was not until she lounged in the pool on her abdomen that the pressure again became tolerable. The pool was invaluable for enabling her to resume breathing over the contractions for the next three hours. In the last hour prior to the birth, the woman commenced her grunting expulsions. As this had not brought her baby to a visible position in that time, I asked her to stand for one contraction to test the power of this feeling. Simply standing engaged the pelvic pressure enough to bring the baby to almost rumping with the first push. The second surge saw the baby rumped and progress so the popliteal spaces (back of the knees) were visible. With the next, he was born to the ankles, then descended quickly to wear his ‘perineal hat’ and his head was gently released without perineal trauma. All of this occurred without a contraction as the women responded to the pelvic pressure.

Assessing the baby

The New Zealand Guideline Group’s 2004 best practice guideline on breech labour and birth, which you can read here, acknowledges that the evidence does not support continuous electronic foetal heart rate (EFM) monitoring by cardiotocography over intermittent auscultation. This is because, just as for well women and their babies with no alerting factors, there are no significant differences in standard measures of newborn wellbeing (including cerebral palsy and infant mortality) with continuous EFM in labour for ‘high risk’ situations, which frank or flexed legs breech presentation at term is deemed to be by some. Only beneficial for its association with a reduced incidence of neonatal seizures, continuous EFM is associated with increased maternal morbidity by way of the accompanying increase in caesarean and operative birth rates Alfirevic et al (2013).

At any given point the midwife needs to know that the baby is coping well with labour by assessment of his movements Banks (2003) and listening to his heart beat. As with any other labour for well women and babies, listening can be easily achieved with a Pinard stethoscope (or handheld, waterproof doppler) during water immersion.

Essential elements of physiological breech birth

Midwives commonly reflect on how their practice changes with attending waterbirths of cephalic presenting babies to become more ‘hands-off’ during birth. Confident that the water frequently dissipates urges to explosively push, while also supporting the woman’s perineal tissues and the baby as he is born, the midwife is drawn to a non touch vigilant attendance. This hands-off in the absence of problems is the ‘golden rule’ during breech birth.

Maternal effort is an important part of achieving a hands-off, spontaneous birth. As with any birthing, the woman needs to be supported to choose positions of comfort in the water which enhance her power and strength – kneeling, squatting, hands and knees or reclining. Whichever birth position is chosen, the midwife needs to position herself so she can see both the advancing baby and the umbilical cord, and be in a position to palpate the umbilical cord if necessary. The midwife may need ‘hands-on’ for the birth of the head but the support of the water usually ensures gentle and woman-controlled birth of the baby’s head. Due to the reduction in gravity and an accompanying reduction in an urge to push for the head, the woman may need to be reminded to release the baby’s head.

Midwives who regularly attend waterbirths with cephalic presentation frequently reflect that if there is a problem during birth, for example, shoulder dystocia, they will initially try to correct it in the pool. This avoids delay while utilising the water’s buoyancy so the woman can move easily to adopt very wide open positions that are needed for manoeuvres. While Ponette (undated1) notes a reduced need for routine manipulations of the breech baby with waterbirth, in the rare circumstance that a manoeuvre is needed to bring down stuck arms and/or flex, cradle and scoop out the baby’s head Banks (1998, pp.88-91), these could also initially be done in the pool, again, avoiding delay. The woman, however, would be asked to get out of the pool if problems were not easily remedied.

The ongoing mosaic of breech waterbirth

Mosaic by Tony Banks

Mosaic by Tony Banks

For some maternity professionals the issue of vaginal breech birth is no longer worth considering in the wake of the Term Breech Trial despite concerns about its methodological flaws  Kotaska (2007); Glezerman (2006); Keirse (2002); Banks (2000). For others it remains a planned option Toivonen et al (2012); Goffinet et al (2006)Hellsten et al (2003); Sibony et al (2003); van Roosmalen & Rosendaal (2002). There will, of course, always be undiagnosed breech babies in labour, irrespective of the degree of antenatal scrutiny.

While some consider a surprise breech as an ‘obstetric emergency’, the manner in which a midwife facilitates a vaginal breech birth that is first diagnosed when birth is imminent is the same as if it was diagnosed antenatally and a vaginal breech birth is planned, albeit the latter having obstetric backup available with the birth in an obstetric hospital.

The use of deep water immersion with mal-presentation (read: breech) is contraindicated in hospital clinical guidelines on waterbirth, and the use of water is absent as a modality in vaginal breech birth guidelines. Embracing these, giving birth in water to a breech baby would be out of the question for some maternity providers. Yet others are very specific in seeing breech presentation as a positive indication for waterbirth because of the buoyancy afforded to the baby and umbilical cord, both of which are kept warm in the water until surfacing into the cooler air Ponette (undated1); Chakowsky: In Napierala (1994, pp. 181-182); Enning (2013). Waterbirthing is contraindicated only if the breech labour is not progressive and/or is complicated Ponette (undated2).

Midwifery can have additional knowledge fragments to obstetric knowledge, gained by our deep relationships with women. Being attentive to women who are called to use water through breech labour and birth, and walking side by side with them during this time, has added to my understanding of facilitating physiological breech birth. We need to be able to share the practice wisdom which comes from our experiences, discussions and reflections. We also need to be able to do this without fear of repercussions that may be activated from that disclosure. As a result, we will continue to find ongoing pieces to the mosaic of breech waterbirth.

Are midwives more ‘at home’ at home?

Evidence that place of birth influences midwifery practice is discussed by Suzanne Miller. In this post, originally published in Birthspirit Midwifery Journal 2009; 1: 7-11, Suzanne introduced her own Masters research which examined similarities and differences in practice of a single group of self-employed midwives in New Zealand.

Photographer: Tony Banks

Photographer: Tony Banks

The shaping of midwifery practice is influenced by a number of things, not least of which is the woman’s chosen place of birth. Isolating the effects of place of birth is achieved more easily in the Aotearoa/New Zealand context, because midwives here follow the woman to her chosen birth place and not vice versa. As background to a recent research project, I explored some studies which focused on how midwives say their practice is altered (or not) by the birth setting they find themselves in. Some midwives who have been asked to describe aspects of their practice in different settings have suggested that they feel more relaxed and are able to establish an “easier interaction” with women when providing intrapartum care at home van Der Hulst (1999). Others have said that they prefer providing care in a hospital setting because they feel safer, because they’re used to being there Davis (2006), suggesting that familiarity with the birth setting is as important for the midwife as it is for the woman.

It seems that most midwives are able to describe ways in which their practice differs according to the birth setting. In a Dutch study van Der Hulst (1999), which surveyed midwives about behaviours which shaped relational care in labour, each of the 99 midwives who participated felt that their care was influenced by the birth setting, though the extent to which this influence was present was different amongst midwives. Relational care (aspects of care which facilitate the natural birth process such as communication and other activities which establish a relationship of trust between the woman and her midwife) was focused on separately from obstetric-technical care (activities such as performing examinations and procedures). She found that there were no differences with respect to obstetric-technical care apart from that midwives adopted a stricter selection process for women planning to give birth at home.

In contrast to this, several differences were found with respect to how midwives provided relational care. When attending homebirths, midwives reported spending more time with women in labour, and visiting more often during the dilation phase. They felt more sense of commitment to the woman, and involved the woman and her partner more in tasks which needed to be done, which van Der Hulst (1999) believed reflects as much the fact that the woman is in her own territory, as the philosophy that the birth process is a normal human experience. She notes that both these things empower the woman’s sense of control in the birth experience.

When providing care in the hospital, the midwives were more likely to sleep(!), be less patient and carry out more of their own tasks. They felt their approach was more efficient, they spent less time with the labouring woman, and they adopted a more formal attitude toward their clients. van Der Hulst (1999) suggests that when practising in hospital, midwives are often confronted with organisational structures and rules which are absent at home and therefore may feel more like they are guests in the hospital, just like their clients.

Different ideas about how the birth setting influences the behaviour of midwives were uncovered by Hunter (2000) in her exploration of how New Zealand midwives perceived differences in their care provision between a small primary maternity unit and a large obstetric hospital. She found that midwives felt more autonomous practising within the small maternity unit, and that they believed they were freer to practice what they called “real midwifery” along with having a greater acceptance of “carrying the can” (p.121). This coupling of autonomy and accountability was seen as one of the key differences between providing intrapartum care between these two settings.

The midwives in her study unanimously preferred providing care in the small unit, despite having experienced emergency situations there. This arose out of their belief that in most cases the outcome would be good, and their belief in their ability to foresee problems and anticipate their effective management. Linked to the notion of foresight is that time in itself may play an important role in women’s intrapartum experiences. The need to transfer out of the small unit if problems arose meant that judgements needed to be made about when the appropriate time to do that was. Time seemed to have different meanings within different contexts, with midwives feeling constrained by the clock and by obstetric definitions of what constitutes acceptable progress at work within the larger hospital.

In a conference paper based on her PhD research examining the culture of midwifery practice in different birth environments, Griffith (1996) suggested that midwives experience a “degree of dissonance as they try to establish congruence between their espoused beliefs and the reality of practice imposed by their work environment” (p. 357). She described her findings not in relation to the birth setting per se (i.e. home or hospital) but around a spectrum based on the degree of medicalisation evident within different care contexts. As the degree of medicalisation decreased, so too did the pervasive nature of the medico-technical focus on care provision. Midwives were more and more able to negotiate defined parameters of safety, and departures from medical protocols were more likely to be tolerated in less-medicalised settings. At the midwifery model end of the spectrum, medical ideas provided a background reference only and there was a recognition that the “ideology of technology was occasionally appropriate and useful” (p. 361), rather than that it defined and determined how care was provided.

Griffith (1996) described how in highly medicalised environments, medical texts and written protocols were considered the ultimate authority, and departures from the protocols were seen as a serious breach of the rules. In the least medicalised environments however, midwives believed that “much of the knowledge that is required for a ‘successful’ birth experience is located in the woman at both conscious and unconscious levels” (p. 364). Thus if women are supported in their choices, these midwives felt that women were more likely to achieve a successful outcome (on the woman’s own terms) and were less likely to experience medical intervention as a result.

The birth environment was also an important determinant of the visibility of midwifery practice in Griffith’s study. She noted that in a very medicalised environment, what was visible, valued and admired in relation to midwifery practice was the ability to use and interpret obstetric technology, inform the doctor and assist competently with the ensuing obstetric tasks. Midwives’ experiential knowledge was invisible in this context and midwives felt deskilled. As medicalisation decreased, midwives’ experiential knowledge became more visible and valued and midwives focused more and more on the centrality of the woman, and less and less on their own active birth skills and knowledge, seeing them as tools only, occasionally useful as an adjunct to their “way of being” as a midwife (p. 365), which was mostly framed around presence and holistic support of the woman.

One of the ways that midwives find themselves seeking to decrease the influence of medicine when caring for women in labour is to be creative with the level of disclosure of what is occurring for the women. Griffith calls this “cheating” (p. 365), and others have applied different terms to it, “obstructing the obstetric gaze” Davis (2006) and ‘misrepresentation’ are but a couple. What these words and phrases are describing are ways in which midwives seek to protect women in labour from medical interventions by obscuring the reality of what is happening. They may do this by action or omission. For example, they may understate the findings of a vaginal examination in order that medically-defined time constraints on labour progress can be achieved. They may decide not to document a particular finding such as full dilatation. An interesting finding in Griffith’s (1996) study was that midwives practising in home settings were much less likely to engage in these tactics, even in transfer situations where they might be assumed to want to protect themselves from judgement or censure for departing from medical definitions of normalcy. This provides a good fit with Hunter’s (2000) discovery of practising ‘real midwifery’ entailing a greater sense of ‘carrying the can’, but also describes the evolution of midwifery practice away from notions of ‘being seen to be good’, and towards honouring midwifery knowledge and ‘telling it like it is’. We cannot hope to demonstrate that a ‘long’ birthing phase once a woman is fully dilated is safe unless we are honest about when we believe it began. We can be clear also about whether a ‘diagnosis’ of ‘second stage’ has been made by observation of a woman’s sounds, movement and behaviour or a vaginal examination.

The provision of a humanistic approach to care was described by Freeman et al (2006), whereby technology was used alongside relationship-centred care. Their study of 104 New Zealand midwives found that the labour care setting did influence practice, identifying that practice was dominated by the medical model of care in an obstetric hospital. Despite this, they concluded that the midwives’ decisions were influenced by the needs of the women rather than the obstetric protocols.

Hunter’s (2000) assertion that midwives’ use of the self is a powerful tool in keeping birth normal by letting labour ‘be’, is echoed in Harris’ (2000)  exploration of why midwives practising in homebirth settings pursue their practice even in the face of political and sometimes social opposition. She also discusses how midwives feel that assisting women at home is an easier way to practice their role satisfactorily, because of the belief in continuity of care and enjoyment of the partnership achieved with women. She suggests that it is easier for midwives to incorporate alternative therapies into practice at home, and that this may be a positive contributory factor in the achievement of normal birth.

Midwives’ use of birthing spaces is another area where differences in practice can be identified. As Davis (2006) describes, at home the birthing space is often already prepared by the time the midwife arrives, although she may add some furniture in the bringing of a birthing stool, or pool. The woman is free to roam at will, utilising a number of spaces within her home to be with others, or alone as her need dictates. The midwife will set up her equipment as unobtrusively as possible, to have at hand as necessary, but not to convey a message about risk or safety. In a hospital birthing space it is much more usual to find the bed as the focal point in the room. Because the woman has only one room, she is constantly scrutinised by those who are with her, which she may or may not want, but over which she has little control. Davis sees the obstetric hospital as a:

“…technology of biomedicine, as the design, furniture, equipment and culture presumes … a passive maternal body that is inscribed as a site of risk. Midwives and women are disciplined in this place, as the technologies of biomedicine attempt to bring their behaviour, choices and midwifery practices in line with obstetric norms” (p. 10).

Photographer: Tony Banks

Photographer: Tony Banks

Midwives will sometimes attempt to mitigate these effects by manipulating the physical environment on arrival at the hospital. The bed may be pushed aside to enable the woman to adopt alternative positions on a mattress on the floor. Lighting may be dimmed, and some equipment removed or hidden. But for the woman and her family there is still a clear message that technology is ready and waiting to be deployed. More recently a type of ‘hybrid’ birthing space has emerged in response to women’s requests for more ‘homely’ environments within institutions Hodnett et al (2006). While attention is paid to ambience in the form of soothing colours, mood lighting and soft furnishings, it is interesting to note as Davis (2006) does, that it is the bedroom which is deemed to be the appropriate room to replicate within the hospital, rather than the living room or bathroom which are the rooms where, at home, more babies are born. Indeed in my own practice I can recall only one instance in eighteen years of a baby actually being born on the bed when it was born at home.

Davis (2006) argues that the ‘obstetric gaze’ is all-pervasive and follows midwives wherever they are practising, expressed as midwives’ fear of litigation and their need to ‘be seen to be good’. This can give rise to other ways in which practice is modified according to the setting. It can be seen in the way midwives document a woman’s labour journey, the idea that if it isn’t written, it didn’t happen. So women’s birthing stories, as told in hospital, unfold in fifteen minute intervals, and despite that this may interfere with a midwife’s ability to ‘be with’ the woman, it is seen as an important protective activity.

So the ways in which midwives have identified differences in practice between birth settings tend to be related more to aspects to do with environment, than to do with assessment and monitoring of the labouring woman. Midwives do not appear to do more or less vaginal examinations, or listen more or less frequently to the baby’s heartbeat in labour van Der Hulst (1999). They say they are more able to allow time, and yet paradoxically are very mindful of time when foresight is required in out-of-hospital birth settings Hunter (2000). They say that hospital protocols are influential in determining their practice, yet are able to stand in their space as midwives and be accountable for stepping outside the protocols when they are satisfied that both the woman and baby are safe Freeman et al (2006).

My own research Miller (2008) (as yet unpublished) asked a small group of midwives who practice in both home and secondary/tertiary hospital settings to describe ways in which their practice was similar and different in each birth setting. Their ideas were very resonant with those already discussed, particularly in relation to their use of time and space. These midwives felt that when they were able to ‘allow’ more time for labour events to unfold, which they found easier to achieve in a home setting, much less intervention occurred in the women’s labours. In contrast they believed that intervention rates were higher when women gave birth in hospital, where time was ‘restricted’ by protocols or guidelines operating within the unit. They felt also that consultation with obstetric staff occurred more frequently when women gave birth in hospital, in association with the sense of ‘restriction’ of time.

With respect to other aspects of care, these midwives reported providing similar care in either setting. When assisting women to work with the powerful sensations of labour, they said they offered the same support in hospital as they did at home. This would most commonly begin with the use of water immersion, massage, homeopathy or acupuncture. They all agreed that they did not offer pharmacological pain management techniques but would comply with a clear request from the woman for them.

The midwives’ discussion was followed up with a national survey in which the labour experiences of over two hundred first-time mothers were compared according to whether they planned to give birth at home (109 women) or in hospital (116 women). All the mothers were cared for by the same midwives, so that differences in practitioner ‘style’ could be controlled for as far as possible. The survey data revealed that the differences in practice that the midwives had identified in each setting were reflected in statistically significant differences in the labour and birth outcomes of the two groups of women. For example, among women who experienced a pushing phase of labour over two hours, in the planned homebirth group 92% achieved a spontaneous birth, compared with only 59% of those in the planned hospital birth group. The other 41% in this group had either a forceps or ventouse birth. This illustrates how when midwives are not constrained by medical ideas about how much time to ‘allow’ for second stage, better outcomes can be achieved, with no compromise to women or their babies.

Differences in the use of space revealed that at home 5% of the babies were born on a bed, and in hospital the figure was 57%. At home only one in five babies were born in the bedroom, which calls into question the persistence of the bed being the focal piece of furniture in a birthspace. The most compelling difference in midwifery practice centres around the consultation practices of midwives. In the home group 16% of women had a consultation in labour with a medical colleague. This figure was 45% in the hospital group. Intrinsically connected to this, 95% of the women in the home group achieved a spontaneous birth, compared with 79% in the hospital group.

The results of this study (only a few examples of which are presented here) provide some evidence that the behaviour of midwives is shaped by the birth place choices of the women in their care, and sit alongside the findings of the previously mentioned studies in relation to this. When women and their families are making choices about where to give birth, we can encourage them to explore these ideas about how their choice can ultimately influence what happens for them in labour. It would seem that not only the behaviour of women is influenced by the birth setting, but that midwives are strongly influenced also by the birthing culture present in different birth spaces.

Midwifery choices

This post was originally published in Birthspirit Midwifery Journal 2010; 5: 37-39. Updated February 2014.

Throughout New Zealand (NZ), it is taken for granted that a midwife needs to be involved throughout the continuum of care of a pregnant woman. From our formal educational beginnings as midwives, we are taught that for well women, pregnancy, birth and mothering are healthy physiological processes. Giving substance to this belief, it is incorporated into the philosophical statements and brochures that inform of the midwife’s service; health and ‘normality’ are in the promotional and professional materials of the New Zealand College of Midwives (NZCOM), and the concept is argued by midwives in forums where maternity services are defined.

What evidence do we have that this ‘talk’ is being ‘walked’? Is birth proving to be less injurious for women than it was 24 years ago? When a woman engages a midwife, can she assume that she will receive midwifery care that is in line with our ethical underpinning of not interfering in normal pregnancy, birthing and mothering processes? In discussing these issues in this post I will focus on birthing.

Photographer: Tony Banks

Photographer: Tony Banks

24 years of midwifery autonomy

The Ministry of Health’s (MOH) Obstetric Procedures 1988/89-1997/98report was released in 1999, nine years after midwifery autonomy was re-instated in New Zealand. The report detailed statistics on caesarean sections, forceps deliveries and vacuum extractions, inductions of labour (both medical and surgical), episiotomies and epidural anaesthesia. The induction of labour rate had quadrupled during the ten years of scrutiny and was 22.1 percent nationally for the 1997/98 period (p. 20). That rate was over twice that which the World Health Organisation (WHO) indicates as appropriate for any region, that is, not more than 10 percent Wagner (1994, p. 149). The national caesarean section rate of 18.2 percent in the 1997/98 period MOH (1999, p. 20) showed an over 64 percent increase over the ten year period Wagner (1994, p. 5). That rate was two to three times higher than that which was seen as the ‘ideal’ (between 5.0-8.4 percent) MOH (1998, p. 59). The authors noted that at least 50 percent of these caesareans occurred unnecessarily as there was no ‘clinical’ reason evident for the operation MOH (1999, p. 28).

So what of the women who did not have caesarean sections, forceps and vacuum extractions – the births that are classified in the data as “other manually assisted deliveries” (read: ‘normal’ births)? The birthing for these women may, or may not, incorporate the procedures of medical induction of labour, artificial rupture of membranes, epidural anaesthesia, episiotomy, manual removal of the placenta and perineal stitching; the way statistics in NZ are published does not allow for linking of interventions to any individual situation. In the 1996/97 year, there were 60,264 of these procedures performed on a total birthing population of 57,180 women. No one knows how many of these procedures were performed on the 67.17 percent of women who had what are whimsically known as ‘normal’ births cited in, Banks (2000, ppp. 30-33).

Fast forward to the Report on Maternity 2010 MOH (2012), the most recent published national births data reported in NZ – a caesarean rate of 23.6 percent, 19.8 percent induction of labour. 24.9 percent epidural anaesthetics,and a 65.0 percent ‘normal’ birth rate. These statistics continue to confirm both the injurious nature of birthing in NZ and that a medical model of maternity care predominates overall, with induction of labour and caesarean section rates alone so disparate from WHO recommendations.

We could dismiss the increasing medicalisation of birth and say NZ is simply following the rest of the western world as childbirth becomes increasingly medicalised. There could be some merit to this option. It is neat, painless (for maternity providers only) and it avoids the discomfort that may arise with honest reflection within the professions. What these data make clear is that there is a very great gap between the midwifery ethos and the reality for childbearing women and babies in New Zealand.

Every time a woman in childbirth undergoes an unnecessary intervention, there is a chain reaction of events which is set in motion:

    • The medical model of birth – our societal norm – is reinforced;
    • The woman’s natural and innate ability to give birth is undermined;
    • That intervention becomes part of the childbirth story she hands on to her sisters, friends and children – a powerful story, deeply personal and repeatedly told;
    • The student midwife in attendance learns birth cannot occur without intervention;
    • And – if the midwife is the one doing that unnecessary intervention – any gap between the spirit of midwifery and the practice of midwifery becomes a yawning chasm.

We cannot determine cause and effect from the statistics but when 91.6 percent of the 2010 women  registering with an Lead Maternity Carer (LMC) in pregnancy had a midwife as their LMC at the time of birth MOH (2012, p. 54) it does beg the question, ‘what was the midwifery role in interventions?’.

The choice of truths

How common it is to hear that many of the unnecessary interventions in childbirth are “women’s choice”. But, how many actually put forward the ‘truth’ about medicalised childbirth to inform women about these choices?

It has been said, “we don’t want to frighten women” by telling them what an induction of labour, epidural, foetal scalp electrode application entails. I suggest women are already very frightened with such high levels of interventions in the maternity service.

Midwives frequently talk about “popping in” or “popping on” invasive technologies and procedures, for example, “popping on a monitor”,  “pop in an IV”, “pop the waters” and so on. We need to reconsider the information we, as midwives, give women about procedures. How many would “just pop on a scalp clip to monitor the baby” if they had to say:

“I am now going to take this twist of wire and imbed it into your baby’s exquisitely sensitive skin. This is a technology that has been proven to diminish the likelihood that you will birth normally. It’s possible that you or your baby could get infections, cuts, scalp abscesses for the baby and electrical burns, but don’t worry, we have antibiotics which may work and help fight some of the infections, the cuts can be stitched and will heal in time and we have plastic surgeons to do skin grafts if need be.”

If we moderate invasive and dangerous technologies by couching them in euphemistic terms, we mute women’s ability to comprehend the very real potential for injury. As Dr Michael Watt, a District Officer of Health back in 1917 questioned – “Would it [Twilight Sleep] have gained any popularity if it had been termed ‘the Dope Delivery Method’ or ‘the Half-Dead Baby System’?” cited in, Mein Smith (1986: p. 83). The spirit of that question is as pertinent today as it was over ninety years ago. Would well women ‘choose’ convenience inductions of labour, electronic foetal heart rate monitoring, artificial rupture of membranes, narcotics, epidurals, arbitrary time limits for the completion of labour if they were asked, “are you ready for us to start the Cascade of unnecessary Intervention?” That is the reality with all the procedures mentioned above for well women; they either have no proven benefit or alter the course of physiological labour and have proven (sometimes considerable) harm for well women and their babies – they are part of the Cascade of unnecessary Intervention.

There are many ‘truths’ in the world but, in NZ, if we offer a midwifery service, the truth we position ourselves in is that for well women birth is a healthy life event unless proven otherwise which needs support rather than medical procedures to ensure safe outcomes.

The choice to stand

To rescue healthy birthing from this point of near extinction can be a daunting task. Yet we have precedents, such as the rescue of home birth from near extinction when in 1973 only 13 home births were recorded throughout the whole country by the then Department of Health Banks (2007 pp. 67-68). In 1996 the rate stood at a healthy six percent of the total birth population Midland Health Funding Authority (1998, p. 57) and could have been at least 10 percent if women were able to access the service National Health Committee (1999). And of course, against all odds, we have the survival of the midwife, with her return as the rightful professional companion to women during the childbirth continuum.

The idea of rescuing something from near extinction is energy draining, isolating and painful. And it is, if one acts alone. However, if supported by your midwifery partner, Collective, other midwives in your work area, midwifery managers in your unit or hospital and NZCOM – then we are talking about building an impenetrable wall of protection around the healthy process of birthing. It is this collectivism which needs to be incorporated into our practice, no matter whether we are home birth midwives or working in the hospitals. We must enact a collective resistance to unnecessary intervention and stop doing the harmful bidding of the various institutional policies and caregivers. Each act of resistance to our continued participation in medicalised childbirth shores up the foundation of midwifery, so the role of the midwife becomes synonymous with the ethos of no unnecessary intervention in ‘normal’ birthing. The beginning step, however, requires a commitment from each individual midwife to stop intervening unless there is an ill health or abnormal process indicator to do so.

The choice to break the silence

Women in New Zealand have continually suffered through protectionist policies (risk management) within women’s health services. The silence of the medical profession in protecting its own has been repetitious and is ongoing. We need look no further than the 1988 Cervical Cancer Inquiry to know that if we are to go beyond a lip service of peer review, we need to ask the hard questions. Midwifery silence about unethical and interventionist midwifery practices is equally self-serving and signifies a significant shift from historical rhetoric that ‘midwives are the guardians of normal birth’.

We need to individually, and collectively (the latter through Midwifery Standards Review process), address the issue of inappropriate midwifery practice when repetitiously confronted with it.


Medicalised birth is very complicated. The practice of ‘real’ midwifery is not. It is just about ‘being’ with women and assisting her and her family by vigilant listening, looking, feeling, touching, thinking, sharing, understanding and/or accepting the knowing or the ‘not knowing’ Pelvin (1996): pp. 15-16. Sure, there will be women and babies who require additional services because of ill health or some event in labour, but we know those women should be, and would be, no more than 10-15 percent of our birthing population if respect for birth as a healthy life phase guided maternity professional actions.

Here we stand, nearly 2.5 decades after the return of legally sanctioned autonomous midwifery practice. There are many ‘good news’ stories to celebrate NZ midwifery but none of these disguise the reality that birthing without intervention in NZ has become endangered. If we verbalise the belief that birth is potentially a healthy experience we need to ensure that midwifery actions universally reflect that belief.

Elusive and contrary: an optimal inter-birth interval for twins at term

Originally published in Birthspirit Midwifery Journal 2010; 6: 55-57.Revised February 2014

Midwifery ethos demands that while remaining mindful of a woman’s ‘birthing potential’ WHO (1998, p. 2) and that any number of eventualities can arise, we nurture the physiological process of birthing in the absence of problems. However, in an ever increasingly medicalised childbirth culture, women experiencing twin pregnancies, some 1 in 80 women, can find it difficult to access support for natural childbirth. At the far end of the spectrum, as one woman related of her initial phone call to a potential caregiver, twins can be seen as “double trouble” requiring automatic induction of labour at 37 weeks, complete with epidural anaesthesia to enable expediting birth of the second twin. Amongst the many decisions that need to be made in relation to birth and care planning is the ‘management’ of birth of the second twin. This post discusses one component of this, namely, the time between the births of the first and second twins, that is, the inter-birth interval.

MATERNITY by Llew Summers Presented to the City of Upper Hutt in recognition of The Year of the Child 1979 (Photographer: Tony Banks)

MATERNITY by Llew Summers
Presented to the City of Upper Hutt in recognition of The Year of the Child 1979
(Photographer: Tony Banks)

Accepted norms and paucity of evidence

There is a generally accepted hypothesis in obstetrics that reducing the time between the births of twins is beneficial and, preferably, should be no more than 15 minutes and should not ‘be allowed’ to exceed 30 minutes Siddiqiu & McEwan (2007) . In the case of term twins with completely separate amniotic sacs, this is primarily, but not exclusively, to reduce the incidence of hypoxic insult to the second twin. Time limits can give rise to a recommendation that labour is sped up by the use of drugs, instruments and/or manipulations of the baby, interventions which may increase perinatal morbidity in themselves, and interventions with which all ‘experts’ do not agree Siddiqiu & McEwan (2007).

Rayburn et al (1984) noted few studies challenge the commonly held inter-birth interval guide and that as early as 1975 it was reported, “the inter-delivery interval does not have any significant effect on the perinatal mortality of second twins” (p. 505). These authors reported a retrospective data review of four regional perinatal centres with 115 women with live-born twins at 34 weeks gestation or more. The inter-birth interval ranged between 1-134 minutes with 15 percent of second babies born >30 minutes after the first. All these infants had Apgar scores between 8-10 at 5 minutes.

Medical literature exploring twin birth intervals cites examples of hours, weeks and/or even months between babies Arabin & van Eyck (2009); Porreco et al (1998); Feng et al (1995); Wittman et al (1992). Many of the labours described are of women with preterm babies – often extremely preterm. Poeschmann et al (1992) reviewed 22 published reports of delay in inter-birth interval. Of the seven cases of first infants born at >32 weeks gestation, the second twins were born at >35-44 weeks, 7-56 days after the first twin (see Table 1).

BirthIntervalTableAs such, while acknowledging that considerable birth intervals do not increase morbidity, this literature may have no bearing for inter-birth intervals where labour starts at term.The midwifery literature does little to answer the question of inter-birth interval when obstetric time frames are uncritically accepted, the issue not addressed at all (see Khalil & O’Brienre (2007); Page & McCandlish (2006, pp. 187-201) for respective examples of this), or only occasional cases of inter-birth intervals of between 1 to 8 hours are published, for examples Noble (2003, p. 264); Anonymous (2003); Sawyer (1996). Even Anne Frye’s (2013) well regarded comprehensive text reports minimal midwifery experience of inter-birth intervals (averaging 1-1½ hours), but she does reflect that time between babies is not critical if there is no bleeding, the baby’s heart tones are fine and the mother is well and happy.

Perhaps the most informative case at term is that reported by Sütterlin et al (1999). An interval of 9 hours and 19 minutes in a twin pregnancy at term followed the birth of the first baby. Artificial rupture of membranes had been performed following the first twin’s birth which resulted in the cervix closing down from full dilation to 5cms dilation. Despite a continuous oxytocin intravenous infusion at maximum dose, uterine activity did not return until eight hours after the birth of the first baby. The second twin was born with Apgars of 9 and 10 at 1 and 5 minutes respectively, and the baby’s neonatal course was reported as “uneventful”. Significant in the decision-making around this birthing was the wish of the mother to wait for a return of her labour.


The information women are given on any recommendations for birthing with twins needs to include the facts that there is a “serious lack of sound evidence upon which to base decisions” Hofmeyer & Drakely (1998, p. 91); Ayres & Johnson (2005) and that the higher incidence of foetal and neonatal complications and mortality associated with twins is attributable to prematurity and its associated problems, rather than simply being a twin per se Rayburn et al (1984); Poeschmann et al (1992). In discussing published accounts that do exist, women also need to be cognisant with the reality that it is likely that accounts with good outcomes are more likely to be offered for publication than those with poorer outcomes.

Finally, we must give women the opportunity to contemplate collective wisdom which gave rise to the statement, “for either twin(s), the indication(s) for any intervention should be convincing [and], compelling …”  Barrett et al (2000, p. 10), as an optimal time between the births of twins has not been established and there is ongoing controversy surrounding labour and birth care with a twin pregnancy Barnett & Ritchie (2002).

Further reading on twins

Extended text of the classic Having twins and more, written by Eizabeth Noble (2003) is available here.

Mamatoto calling

This post was originally published in Birthspirit Midwifery Journal 2009; 1: 43-46. Updated February, 2014

Each of Jaynie’s three labours built up over several days before she had contractions that were frequent enough for her to determine she was in labour. During these times she carried on with everyday activities such as attending yoga classes in her first labour and home-schooling her two daughters during the third. This period of labour was valued and enjoyable for Jaynie, spent predominantly in intimacy and seclusion with her family.

Jaynie liked midwife attendance in labour when contractions were intense but the midwife belonged on the periphery of the birth space. Jaynie’s husband, Ken, provided all the physical and emotional support with the midwife there to provide only the patient vigil. Jaynie had a deep connection with her babies throughout the continuum of childbearing so gaining affirmation of the baby’s wellbeing was through her comments about the baby’s movements and hiccups with minimal aid of a Pinard stethoscope.

If one were waiting for the anxiety of transition that is predicated in many texts, the midwife would miss the forerunner to Jaynie pushing as the spacing out of contractions is the only sign that birth is near. It is when Jaynie begins to shorten her quiet outward breath with almost imperceptible pushing that the baby’s imminent birth is signalled. With her first two births the urge to push “came out of nowhere”; during the third, she was conscious of pushing because she was tired and wanted the labour to end. Jaynie’s waters normally go within the last few moments of labour and the heavy show, often attributed to full dilation, appears moments before the baby’s head. As a sufferer of endometriosis prior to having children, Jaynie’s ability to deal with pain had already been fully tested prior to her first baby.

When her second and third babies were born she lifted one to the surface of the water herself and drew the other close after being handed to her. Her babies are ‘in arms’ babies. They sleep and rest in her arms, cheek on bare breast or in the arms of another family member.

The benefit of hindsight of having attended two of Jaynie’s three home births, and hearing the story of her first birth along with reading the midwifery notes of that birth, allows me to see the pattern over these three births. However, listening to Jaynie tell the story of her first labour and birth was disturbing for me the first time I cared for Jaynie in her second pregnancy. Evident in her story was a cascade of intervention – not the usual induction or augmentation of labour with vaginal prostaglandins, Syntocinon infusion, epidural anaesthesia and operative or surgical birth. This was a home birth story that Jaynie related, complete with of a cascade of intervention, as follows.

For this first baby, Jaynie’s labour rhythm developed over two days. She arranged in the evening of the second night for the birth pool to be dropped off before bathing and going to bed. She couldn’t sleep after 4am and used the pool for relaxation and pleasure – a pleasure still evident in her smile at this point as she related her birth story to me. Soon after the midwife’s visit at 9am Jaynie was examined vaginally and her cervix was estimated to be 6-7 centimetres dilated.

Jaynie felt pressure from the midwife to progress in labour and took the cell salts Mag Phos and Calc Phos which were recommended to strengthen and speed contractions. These made Jaynie’s contractions more intense. When the vaginal examination was repeated four and a half hours later, her cervix had opened to be 7-8 centimetres and the baby had moved down to be at Station 0. This was seen by the midwife as not enough progress and Jaynie’s waters were artificially ruptured following which she was given the homeopathic Lobelia 200c to assist retraction of a thin lip of cervix.

Jaynie used the pool after this time and, while the midwife noted labour slowed, Jaynie felt it was strong in the pool. With all the focus on making labour stronger by artificial rupture of membranes (ARM), cell salts, homeopathy and different positional techniques, the toilet was the only place she and Ken felt they could be alone, and Jaynie intermittently sought sanctuary there.

She was examined vaginally for a third time in seven hours as she wanted to push. This was a phase that Jaynie remembers as wanting to lie down and relax but she was urged by the midwife to be upright as the latter had a sense of urgency that the baby had to be born, the reason for which was not reflected in the midwifery notes. It may well have been the presence of meconium which became known with membrane rupture as abnormal heart tones were not indicated in the midwifery notes. The midwife’s concern was enough for her to get Jaynie to leave the birth pool where she had been relaxing, and onto a floor mattress. Jaynie pushed expulsively on the thin anterior lip of cervix and her first daughter was born in three pushes while the midwife performed perineal massage.

There was a brisk 500 ml blood loss estimated. Jaynie had wanted the umbilical cord to remain attached to her daughter’s placenta but now the midwife’s focus turned to the birth of the placenta. The umbilical cord was clamped and cut, and an intramuscular injection of Syntocinon was administered without Jaynie’s permission.

Her baby had immediately latched on, and was feeding determinedly. Jaynie felt very “scattered” with the multiple interferences of late labour and, while her baby still wanted to feed, she was instructed to give the baby to Ken so she could “be in her body to push”. This was to oblige the midwife’s need for placental birth to be achieved.

The blood loss had stopped as quickly as it had started and Jaynie’s uterus remained well contracted with minimal further blood loss. While there was no perineal trauma, bilateral labial tears were later stitched.

Jaynie was given Kali Carb 200c to prompt birth of the placenta.

After two unsuccessful attempts at controlled cord traction and with a Syntocinon infusion running, Jaynie was transferred to hospital two hours after the birth for manual removal of the placenta under epidural anaesthesia – a matter Jaynie felt she had no other choice than to make. Once manual removal was achieved, and with antibiotics administered, Jaynie was left to recover from this process which she described as “frightening and painful and leaving [her] feeling as if [she] had been invaded”.

While she was now finally able to focus on her daughter, the intimate family time that she and Ken had planned had to be abandoned as Ken was prevented by hospital staff from staying the night. He would spend the night in their van in the hospital car park.

Jaynie had wanted to be discharged immediately but felt exhausted and weak following the epidural and a shower, so stayed the night. She did not sleep at all overnight and spend these hours gazing at her treasured daughter. When she returned home at 7am, she, Ken and the baby went to bed for a week and were well supported by others who brought them meals.

Following the birth of her third and last child, I revisited all the midwifery notes and Jaynie’s first birth story. The discomfort I felt when she originally told me this first birth story percolated up again. The way she had laboured with her first baby and the time it took for her to do so were well within the bounds of my experience of a ‘normal’ labour. A smooth and progressive pattern of labour had been evident with the increasing strength and frequency of Jaynie’s contractions, her knowledge of the intensifying labour over the preceding time, and her hormonal state which necessitated her withdrawal from outside stimulus. This knowing of progressive labour would have been supported by ongoing descent of the baby’s head assessable through abdominal palpation and observation of her back, the lengthening and deepening burgundy of the buttock crease, and her increasing birth energy. After having attended many similar first labours, I could see no role for stimulation of such a labour with cell salts or homeopathic remedies.

It was (and is) equally difficult to see the need for artificial rupture of membranes based on vaginal examinations – a test known to be subjective, imprecise and poorly reproducible Downe et al (2013); Buchmann & Libhaber (2008) & (2007); Letic (2003). These examinations gave poor information. For example, Jaynie’s cervix was noted to have dilated to 6–7 cm with the first assessment and 7–8 cm with the second examination four and a half hours later. This one centimetre difference in each individual finding represented 16.6 percent and 14.2 percent variance, respectively. Further, the potential two centimetres increase in dilatation in four and a half hours – that is, up to a 33.3 percent increase – must be seen as ‘adequate’ as it spans the stage when, prior to seven centimetres dilatation, it is not uncommon for the cervix to remain unchanged for more than two hours in a first labour Zhang et al (2002).

Acting on the (mis)information found at vaginal examination initiated the cascade of intervention. It began with the use of cell salts and homeopathic remedies and was furthered with ARM – a surgical technique which has no place in a physiological labour Smythe et al (2013). Such interventions irrevocably alter labour and, for Jaynie, contributed to scattering the deeply internal hormonal and emotional connections within her labour. Consequences of these interferences were played out in the retention of her placenta which was firmly adherent in the fundus.

Had Jaynie been supported in a non-interventionist way in this normal labour, it is very probable that she would have given birth to her placenta within an hour as she did with the two births that followed. Jaynie would then have been able to flow the mamatoto (motherchild) of pregnancy, without disruption, into the attached parenting that underpins her mothering. And, finally, Jaynie’s plan for natural childbirth, devoid of unnecessary intervention, implicit in the decision to birth at home, would have been honoured.